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Medicare Denying Total Knee for Not Medically Necessary

  1. #1
    Cool Medicare Denying Total Knee for Not Medically Necessary
    Medical Coding Books
    We have received a couple denials from Medicare for total knee arthroplasties stating "Your Part B claim cannot be paid as the hospital's Part A claim has been denied for not medically necessary".

    The hospital's coding matches ours and should have paid as far as we can see. I do recall hearing something recently about Medicare changing the protocol guidelines for total joints but I cannot remember where I heard it or read it. I have attempted to find a new policy on the CMS website but it just brings up a bunch of junk that have nothing to do with what I'm looking for.

    Any thoughts or advice? We would really appreciate it!!

  2. #2
    Location
    Hartford, CT
    Posts
    723
    Default
    Have you called the hospital? Our office has found that helpful because then you can work together and appeal claims on the same basis. Since hospital biling is so different that physician billing there may be other factors involving the hospital that you are not aware of. Just a thought.
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

  3. #3
    Default
    could be based on the type of admission it is--I know that if they are admitted for Mental Health it gets pretty tricky. What was the diagnosis code that you used?
    Tina Wosmek CPC, COSC

  4. #4
    Default
    715.96 was our dx as well as what the hospital used. This is the code that has been used for as long as I've been doing this which is what leads me to believe this is a new policy that Medicare has instituted.

    The hospital billing staff seems to be less than cooperative in these situations, unfortunately.

    Thanks!

  5. #5
    Location
    Greater Pittsburgh
    Posts
    390
    Default
    Have you called Medicare, could it have been an error on their part? I seem to remember getting an email related to the DX. I'd give them a call. If you & the hospital both used the same DX and it was billed correctly for the place of service (in pt?) then I would investigate further with Medicare.
    Last edited by jdemar; 01-17-2012 at 09:03 AM. Reason: Medicare
    jdemar, CPC, CMA

  6. #6
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by broncsrox View Post
    715.96 was our dx as well as what the hospital used. This is the code that has been used for as long as I've been doing this which is what leads me to believe this is a new policy that Medicare has instituted.

    The hospital billing staff seems to be less than cooperative in these situations, unfortunately.

    Thanks!
    Heproblem is the dx code, 715.96 is UNSPECIFIED, as to th type of osteoarthritis.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    For Total Knee/Hip do not use an unspecified code. You need to be exact on why patient had to have this done. If the doctor dictated you can also use morbid obesity or obesity as a 2nd code.

  8. #8
    Default
    Is that new for Medicare that 715.96 is not allowed? I literally have been using 715.96 for TKA for 5 years with no problems whatsoever.

  9. Default
    Quote Originally Posted by broncsrox View Post
    Is that new for Medicare that 715.96 is not allowed? I literally have been using 715.96 for TKA for 5 years with no problems whatsoever.
    so has our office....would be curious to see any new protocols/guidelines....

  10. Default
    Double-check your place of service on claim.

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